Primary Health Care: Open Access
Holst, Primary Health Care 2015, 5:2
http://dx.doi.org/10.4172/2167-1079.1000194
Review Article
Open Access
Rethinking Medical Training in Germany Towards Rural Health Care
Jens Holst*
Institute of General Medicine and Family Medicine, University of Magdeburg, Sachsen-Anhalt, Germany
Abstract
Germany is facing increasing challenges to safeguard universal access to quality health care since the provision of
medical services in rural areas is shrinking. International evidence provides two important lessons learned: strengthening
primary health care can contribute to reducing the undesired effects of social and demographic transition; and tax-borne
or government healthcare systems are more effective in promoting primary health care. This paper argues that structural
conditions in the healthcare sector as such and in medical faculty prevent decision makers from effectively reacting
either through more adequate contractual arrangement between the various stakeholders of the corporatist system or
by enforcing a more suitable education of health professionals. While innovative models of healthcare provision and
financing inevitably clash with vested interests, the reforms needed in medical training challenge the current design
and prevailing incentives of medical schools. Beyond convincing concepts, strong political will be indispensable for
implementing the reforms needed for ensuring countrywide access to health services.
Keywords: Rural health; Health care system; Corporatism;
Decentralisation; Medical training; Social accountability
Abbreviations: WHO- World Health Organization; SHI- Statutory
Health Insurance; GP- General Practitioner; DZNE- Neurodegenerative
Diseases
Introduction
Germany is generally recognised as a country spending a relatively
high share of its gross domestic product for health, providing universal
health protection, quality health services and good access to care
[1,2]. Being a federal republic, Germany has implemented a series of
equalisation and compensation mechanisms in order to achieve the
constitutional right of all citizens to benefit from equal living conditions
all over the country. The right to health, however, is increasingly
challenged due to growing regional inequities especially with regard
to health care provision. Although Germany is a small country in the
centre of Europe, rural areas are facing the challenge to ensure access to
health care within the region. As medical specialists and hospitals tend
to practice in urban centres, providing general and family medicine in
remote areas is the most important measure for safeguarding health care
outside urban areas. The natural turnover of elderly rural practitioners
combined with the low level of recruitment and increasing problems to
retain health professionals in rural locations calls for immediate action.
International evidence shows that supporting medical careers in
rural areas through graduate training is an effective and sustainable
means for reducing the rural exodus of physicians and preventing
severe undersupply of medical services in rural areas [3]. Health
scientists and politicians agree upon the need to re-orientate medical
training towards family and rural medicine. However, a series of
systemic, structural, institutional, political and ideological conditions
make the necessary reforms and transformations difficult to implement.
This paper analyses the most important constraints for effective policy
measures to strengthen family and rural medicine and give primary
health care a stronger role. Based on a brief introduction of relevant
framework conditions and features of the German healthcare system
as a whole, the paper will mainly describe and briefly discuss the most
important constraints for strengthening primary medical care, which
exist at institutional level and at medical schools.
Background
Germany is the most populated nation in the European Union. Like
other developed countries, the German society is mainly urban with
Primary Health Care
ISSN: 2167-1079 PHCOA, an open access journal
only 18.6 million out of 80 million people (23,06 %) living in sparsely
populated areas, which in turn comprise two thirds of the national
territory (66,54 %). Population density varies between 1,606 per km2
in densely populated areas and 78 per km2. In the East German federal
state of Saxonia-Anhalt in turn, more than two in every 5 citizens
(41.4 %) live in sparsely populated regions and less than 25 % in urban
areas [4].
Its per-capita gross domestic product of 35,200 EUR [5] makes
Germany one of the wealthier nations among European and other
industrialised countries. Despite some regional disparities, average
household income is generally higher in the Southern states compared
to the North and in former West compared to East Germany. Regardless
of the given variations, household income tends to be lower in sparsely
populated rural areas [6]. Higher unemployment rates and a larger
share of elderly often accomplish the situation in economically less
developed regions.
Compared to other industrialised countries, Germany depicts a
relatively high overall density of practicing physicians (3.8 per 1,000
populations) but they are unequally distributed. The populationphysician ratio varies between federal states and is much higher in city
states compared to those with lower population density. In addition
there is a remarkable difference between the Northern and Southern
parts as well as between former East and West German regions. With
regard to the number of accredited outpatient physicians, coverage
varies between 197/100,000 population in Germany’s largest city of
Berlin and 134/100,000 in the former East-German state of Saxonia
-Anhalt [7]. Specialists in rural regions have to take care of minimum
54 % (ophthalmologists) and up to 127 % (neurologists) more people
compared to their colleagues in urban centres [8]. The situation is less
pronounced for general practitioners but still significant; even without
taking into account the major cities, which depict a clear oversupply of
*Corresponding author: Jens Holst, Institute of General Medicine and Family
Medicine, University of Magdeburg, Sachsen-Anhalt, Germany, Tel: +49-391-6721009; E-mail: [email protected]
Received June 11, 2015; Accepted July 03, 2015; Published July 10, 2015
Citation: Holst J (2015) Rethinking Medical Training in Germany Towards Rural
Health Care. Primary Health Care 5: 194. doi:10.4172/2167-1079.1000194
Copyright: © 2015 Holst J. This is an open-access article distributed under the
terms of the Creative Commons Attribution License, which permits unrestricted
use, distribution, and reproduction in any medium, provided the original author and
source are credited.
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Citation: Holst J (2015) Rethinking Medical Training in Germany Towards Rural Health Care. Primary Health Care 5: 194. doi:10.4172/21671079.1000194
Page 2 of 6
generalists, population coverage varies significantly between urban and
rural areas [7].
enrolled in SHI through contributions paid by the Unemployment
Insurance or the municipalities, respectively, on behalf of them.
The German Healthcare System
Civil servants benefit from a tax-funded government employee
benefit scheme paying a percentage of the costs, and cover the remaining
costs with a private insurance contract. Persons with incomes above
the prescribed compulsory insurance level, self-employed persons and
university students have the option to choose between statutory and
private insurance. Together with Chile, Germany is the only OECD
country with universal population coverage that allows better-off
citizens to fully opt out of the public health-insurance system and
enrol into private insurance. In addition, various types of private
supplementary insurance are available as add upon to the statutory
sickness funds.
Germany’s healthcare system is internationally known as a pioneer
of social health insurance initiated as early as in 1881 under Chancellor
Otto von Bismarck who lent his name to one of the basic types of health
financing systems [9]. After stepwise expansion of both population
coverage and benefit packages, health care in Germany is now universal
with practically all residents covered by comprehensive healthcare with
relatively low out-of-pocket payments. Beyond this general condition,
the German health system and particularly the complex interaction
of various decision makers are not well known at international level.
Confusion often arises from the fact that in many countries “public” is
understood as synonym of “state-run” what makes public-private the
only alternative in the categorisation of political or economic entities.
But the issue is a bit more complex. In Germany – like in other countries
with social insurance systems – the State decided to outsource a series
of functions and responsibilities to special bodies in order to delegate
various tasks to self-governed and often decentralised institutions.
In the health sector, this mechanism applies to both payers and
providers: Statutory Health Insurance (SHI) is responsible for enrolling
beneficiaries and for collecting, pooling and allocating financial
resources for health care; panel physicians are mandated to be members
of the regional Statutory Health Insurance Physician Association if
they want treat and be paid for SHI beneficiaries. Both institutions are
mandatory for insurees and panel physicians, respectively, regulated
by public law, and supervised by the Ministry of Health; but they are
autonomous, not-for-profit and self-governed. Despite the high level of
autonomy, the specialised bodies are public in nature; they act on behalf
of the State and have to negotiate all relevant arrangements including
remuneration issues among themselves.
Everybody residing in Germany is mandated to take out health
insurance; and entitlement to health benefits requires enrolment and
regular contribution payment. Services are provided free of charge
at the point of service except some minor co-payments. Practically
90 % of the population living in Germany is mandated to enrol into
Statutory Health Insurance (SHI - Gesetzliche Krankenversicherung).
Besides SHI covering the vast majority of residents, the better off with
a yearly income above almost €50,000 (USD 54,000), self employed,
and civil servants for complementary coverage beyond the taxfunded government employee benefit scheme can opt for private
health insurance (about 11 % of the population). Salaried workers
and employees below that income threshold have freedom of choice
between the currently 120 public non-profit “sickness funds” and
are automatically enrolled via their work places. The contribution is
basically shared between employer and employee (7.3 % of the salary
each), but the latter have to pay an additional 0.9 % of their income.
Contribution rates are basically the same for all enrolees, but statutory
health insurance funds can charge an additional income share if the
revenue turns out to be insufficient to cover the expenses. This is
because SHI applies the pay-as-you-go principle meaning that they
have to operate with the current revenue without making benefits or
debts.
Provider payment is negotiated in complex corporatist social
bargaining procedures among specified self-governed bodies (e. g.
physicians’ associations) and the Statutory Health Insurance as a whole.
The sickness funds are mandated to provide a unique and broad benefit
package and cannot refuse membership or otherwise discriminate on
an actuarial basis. Unemployed and social welfare beneficiaries are
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ISSN: 2167-1079 PHCOA, an open access journal
Both public and private health insurance cover a broad scope of
health services ranging from preventive care over highly specialised
medical treatments to rehabilitation services. The benefit package to
be covered by statutory health insurance is defined by the so-called
Federal Joint Committee (gBA) equally composed by representatives
of payers and providers – namely health insurance funds on the one
side and physicians and hospital associations as well as other suppliers
on the other side – and the chairman. The Federal Joint Committee is
the paramount institution of the German corporatist healthcare system.
System Constraints for Strengthening General and Rural
Health in Germany
Corporatism in the Healthcare Sector: The fact that Germany’s
healthcare sector is the archetype of a decentralised corporatist system
has important implications for any strategy that aims at strengthening
primary health care. Since the state has delegated powers and decisionmaking competences to nongovernmental public bodies, it is much
more challenging or even impossible to directly implement political
decisions in daily practice. Statutory health insurance funds and
provider organisations such as office-based SHI physicians’ and dentists’
associations or hospital federations are influential players within the
German health sector. As the duty and power to decide upon benefits,
prices, standards and other topics related to healthcare provision
relies on self-governed “corporatist” bodies, imposing public policies
is not a minor task since all stakeholders have their own interests and
priorities. It is the job of legislators to promulgate laws, but for instance
the regulations regarding outpatient care have to be agreed with the
regional associations of panel physicians and statutory health insurance
funds, and also between the two bodies [10].
Compared to countries with state-run or tax-borne healthcare
systems, the various stakeholders in the German health sector have
larger autonomy and better conditions to champion their own interests.
Strengthening primary health care implies to face all interest groups,
which are not benefiting or even have competing priorities. To start
with statutory health insurance, beyond the theoretical finding that
strong primary care has the potential to rationalise the use of health
services and reduce health expenditures insurance funds do not depict
effective strives for promoting primary health care compared to other
levels of care. The lack of integration between primary, secondary and
tertiary services, and the duplication of specialist services in outpatient
and inpatient care remain common, and the waste of resources persist
[11]. The insidious commercialisation of both health financing and
healthcare provision through a series of market-oriented reforms
[12,13] further increases the already existing barriers to strengthening
primary health care and its role in the German health sector.
There have been different approaches to prioritise general medicine
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Citation: Holst J (2015) Rethinking Medical Training in Germany Towards Rural Health Care. Primary Health Care 5: 194. doi:10.4172/21671079.1000194
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in ambulatory care such as implementing co-payments for direct use
of specialised services without referral by a general practitioner (GP)
or various strategies to set up managed-care models based on general
practitioners. The so-called practice fee could not develop the intended
steering effect as the original idea was undermined by introducing a
general co-payment for all office visits, while GP-centred managed care
remained financed by extra-budgetary funds and has not yet made
it into regular healthcare provision. Moreover, patients do not need
to formally register with a practice [14]; and all attempts to promote
the use of generalist health services clash with people’s freedom of
physician choice that has become a highly relevant commodity among
in Germany [15].
Hierarchical Relationship of Health Professionals
In addition, the established working relations among the various
health professions hamper a stronger role of primary care. German
legislation defines physicians as the leading professional group in the
healthcare sector; all other health service providers can only deliver
diagnostic and therapeutic services on indication of a medical doctor.
This reduces primary health care to a large extent to general or family
medicine and prevents other health professions from playing a more
proactive role in providing outpatient primary care. Despite some
recent pilot projects, where selected tasks are delegated to medical
assistants, many relevant functions are restricted to officially registered
physicians.
Implementing more participatory and interdisciplinary approaches
in primary health care calls for essential changes in the German health
sector [16]. The reforms required for implementing innovative models
of healthcare provision, which are promising to tackle the arising
challenges in general practice and particularly in rural health, will
inevitably create clashes with relevant stakeholders, particularly with
physicians and their legal bodies. The prevailing role of medical doctors
in healthcare provision is reflected in their predominant position in
the health sector. This applies especially to outpatient care where panel
physicians have shown much resistance to delegating medical services
to nurses or medical assistants like in other countries; at the same
time, however, they continuously complain about the heavy workload
generated by the perceived high demand of patients [17].
But it is not only the willingness of German physicians to cooperate
with other health professionals that offers much room for improvement.
Statutory health insurance funds for outpatient care are channelled
through the panel physicians associations according to the agreements
achieved in regular negotiations of the two autonomous bodies. These
funds are used to pay for outpatient medical and other health services
including physio- or ergotherapy and home care. Access to other health
professionals in outpatient care depends hence on physicians will
to provide the respective indication and financial approval because
services provided outside the medical office put a strain on the panel
physician office budget. The need of prescriptions and financial
implications provides physicians with the gives medical doctors full
control and sovereignty regarding the use of or access to non-physician
health services.
Another challenge for general practice derives from the fact that
the overall budgets allocated quarterly by statutory health insurance
for outpatient care are assigned to all panel physicians in a regional
association. This implies an on-going battle for a piece of the cake
between generalists and specialists, on the one hand, and between the
different specialist groups, on the other hand. The position of specialists
within the associations has traditionally been stronger compared to
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ISSN: 2167-1079 PHCOA, an open access journal
generalists, and there is no change in sight. This makes it extremely
difficult to strengthen primary health care at provider level. The
autonomy and self-governance of statutory health insurance physician
associations prevents the national as well as regional governments from
imposing interventions and reforms in healthcare provision in order to
strengthen the primary level.
Federalism in Healthcare Provision and Academic Institutions
Germany is a federation composed by 16 Länder that depict quite
heterogeneous characteristics with regard to surface, population size,
economic activity, income and others. While three of them are urban
states and hence do not face the challenge to care for remote areas,
others are relatively large and show a variable mix of urban and rural
regions. The federalist structure is reflected in a number of political and
institutional structures. Regarding healthcare and medical education
in Germany, federalism has strong impact on both. For instance,
the Länder are responsible for regional hospital planning and for
covering hospital infrastructure and investment. The former regional
organisation of some large social health insurance schemes has stepwise
disappeared due to concentration and merging processes under the
existing rules of competition [10].
Particularly relevant for primary health care is the fact that
outpatient care is organised according to federal states. Medical
Chambers and especially associations of statutory health insurance
physicians are still organised at federal-state level. Since the latter are
responsible for safeguarding access to healthcare in a defined region
and for remunerating outpatient-care providers, all interventions,
changes or reforms concerning primary health care have to be
negotiated with the regional representations of panel doctors, primarily
when it comes to agree upon financial responsibilities and obligations.
The national federation of panel physician associations can provide
recommendations and guidelines but decision power is at regional level.
Federalism is also very strong in the German educational system
since the responsibility for primary, secondary and tertiary education
lies exclusively on the Länder. Since practically all medical schools
in Germany depend on regional governments, it is not an easy task
to implement changes in university training according to national
policy decisions or priorities. The federal government cannot prescribe
nationwide curricula, teaching and learning content or other elements
of undergraduate training; on the other hand, universities have – at
least in theory – the chance to adapt their priorities and education to
specific needs in the Land they are located in. Local or regional priority
setting in research and academic training, however, is not yet anchored
in science policies in Germany and not even included in current
recommendations for higher education [18]. This paper illustrates
that the medical school at the University of Magdeburg is an eloquent
example for the rather ossified curricula structures of the German
university system. These general conditions are particularly relevant
for the on-going efforts to strengthen primary health care through
adequate undergraduate training, as national policies cannot be directly
implemented in medical training unless federal-state governments
follow voluntarily the respective guidelines.
Medical Schools’ Prioritise Highly Specialised Care
Due to the corporatist structure of the German healthcare system,
vocational training of general practitioners is under the auspices of the
regional chambers of physicians while medical schools or departments
of general practice and family medicine are not formally involved [14].
The historical separation of postgraduate training from academics has
not only prevented research to be a part of vocational training, but also
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Citation: Holst J (2015) Rethinking Medical Training in Germany Towards Rural Health Care. Primary Health Care 5: 194. doi:10.4172/21671079.1000194
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hampered the awareness of primary care research and evidence-based
medicine in clinical practice in Germany. On the other hand, academic
departments of general practice and family medicine or primary
health care are quite recent in German universities starting only in
the late 1970s. It is striking that medical schools ultimately depict an
insufficient level of preparedness - and apparently also of willingness
- to give adequate answers to the growing challenge of lacking family
and general medicine and under-served rural regions. To a large
extent, practical medical training occurs at university clinics and wellequipped hospitals providing (highly) specialised medical care instead
of general and family medicine services. Due to traditional role models,
social reputation, lacking opportunities to get into general and family
medicine, and the above-mentioned provider payment mechanisms,
this condition is extremely difficult to overcome.
Moreover, a series of relevant structural changes corroborate
the trend of medical schools to give family and rural health only a
secondary or even tertiary role in undergraduate medical training.
During the last 25 years, the business model of German universities
- which are essentially public and responsibility of the Länder - has
undergone fundamental changes: “Third-party resources” have
increasingly replaced the hitherto budget financing through federal
states. The selection and appointment of professors and university
teachers does not depend only on academic and professional reputation
but increasingly also on the ability to access third-party funding [19].
Moreover, the academic world has increasingly become competitive
and market driven [14]. The options for defining research according
to public priorities and democratically determined requirements, and
the independence of scientific research have lost importance since
academic activities are often determined by external demand, potential
marketization, opportunities to publish in ranked journals and even the
obsession of researchers to make themselves mark.
It would be naive to expect these underlying conditions do not have
impact on staffing, equipment, priority setting in research and medical
education. The University of Magdeburg is a shining example for the
huge distance that often exists between academic research and real-life
needs. Magdeburg is the capital of the federal state of Saxonia-Anhalt
that stands out for being one of the economically least developed
Länder with limited options to grow, a number of rather remote rural
areas, demographic ageing enhanced by rural exodus, and a generally
low level of education. Nonetheless, the university in the region has
decided to put priority on scientific – including basic - research in two
areas, namely immunology and neurosciences.
There is no doubt about the relevance and importance of basic
research as indispensable approach for developing and applying new
diagnostic and therapeutic pathways and ultimately for improving
health care. With regard to the University of Magdeburg, the capital of a
rather poor federal state, the allocation of limited resources is arguably
a valid question. The need to acquire third-party financing from public
institutions that have an interest in promoting Länder of former EastGermany and from private companies, which also receive subsidies for
investing in lower developed regions, is a strong driver for academic
institutions to stand out for their excellency in specific areas.
On the other hand, personnel decisions together with ambitions
and the general climate in the academic world mainly driven by
publication pressure, reputation and individual ambitions, but also by
competition, favouritism and particularly by main-stream trends are
likewise important for priority setting in higher education. Actually, a
positive feedback loop between the endeavour for third-party funding
and the struggle for scientific reputation is the main driver in universityPrimary Health Care
ISSN: 2167-1079 PHCOA, an open access journal
based research and education; this makes the medical academic system
susceptible to loosing contact with real health-service needs over time.
Medical training focuses largely on acquiring biomedical information
and technological skills. The worldwide prevalent model of medical
schools tends to direct students away from developing the competences
and attitudes required to understand and address the determinants of
health [20]. At the same time, however, medical schools are legitimately
expected to be accountable for covering the needs of society and the
living environment – particularly if they are public like in Germany.
General conditions of university research force academics
sometimes into linkages, which rather obey political economy than
appropriateness or rationality. A joint project of the Institutes of
General and Family Medicine and of Social Medicine and Health
Economics at the University of Magdeburg with the German Centre of
Neurodegenerative Diseases (DZNE) might serve as an example. The
so-called Neurotrans project “Dementia in research and practice” aims
at improving linkages between basic research and outpatient generalist
care. The collaboration might be useful for recruiting “communityacquired” dementia patients, but the objective to mediate diagnostic
and therapeutic options in a manner suited to patients seems to be
extremely ambitious as long as these options are still unexplored and
have not proven to be effective. Such cooperation would make much
sense in the fields with convincing evidence for the effectiveness of
medical procedures and treatments in order to overcome the huge gap
between clinical study results and community effects in outpatient care,
e. g. for cardiovascular diseases or diabetes mellitus.
With regard to the early detection and effective treatment of
dementia, however, progress is still to be seen and still requires much
basic research before medical science will be able to offer something
at this point of time. Attempts to bring together theoretical and basic
neurosciences with health services research, particularly in general
and family medicine, are hence rather ambitious or even inappropriate
for health problems with poorly developed therapeutic approaches.
The rationale behind the cooperation of the two university institutes
in Magdeburg with the DZNE comprises the need to create links with
“fashionable” topics and to adapt to exogenous priority setting of the
medical school as a whole but does not seem to be based on rational
arguments and existing demand from a general medicine perspective.
At the same time, the focussed and highly specialised orientation of
medical schools restricts the space for research on the most pressing
challenges of general and family practice and relevant topics of health
services research in the region. Priorities in the field of medical research
are hardly appropriate for improving undergraduate medical training
and even less for tackling the major health needs in Lander like SaxonyAnhalt.
Discussion
Rethinking and reforming medical school design and orientation
are indispensable for making clinical research, health care services and
also undergraduate medical training more suitable to the current and
future demand. Basic scientific research is of low relevance for preparing
medical students and hardly included in medical undergraduate
education. Moreover, highly specialised and focalised research does not
contribute to overcome the most pressing constraints and challenges
such as overspecialisation of health care and underservicing in rural
areas. For safeguarding high-level health care all over Germany, both
academic and political decision makers will have to promote necessary
reforms to overcome the self-referential academic system, and provide
adequate incentives for needs-based medical research and training.
Properly designed and mandated accreditation systems for medical
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Citation: Holst J (2015) Rethinking Medical Training in Germany Towards Rural Health Care. Primary Health Care 5: 194. doi:10.4172/21671079.1000194
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schools will have to abandon traditional pathways and reflect both
social accountability and excellence of education.
Institutions demonstrate social accountability by committing
themselves to addressing and solving challenges and demands of the
society. The World Health Organization defines social accountability
of medical schools as “the obligation to direct education, research and
service activities towards addressing the priority health concerns of the
community, region, and/or nation they have the mandate to serve” [21].
More recently, social accountability has been identified as a change
agent for the future with the potential to deliver high-quality education
and graduates who respond to societal needs [22]. In the case of the
University of Magdeburg medical school there is much room for further
developing and underpinning social accountability by better taking up
the demands of the surrounding geographic region and particularly the
obvious need for safeguarding rural health care according provided by
the German constitution.
Moreover, a series of rather fundamental changes will be required
for achieving and ensuring both responsibilities for the comprehensive
health care commitment to community-oriented biomedical and healthservice research in the region or in a defined part of Saxonia-Anhalt. At
faculty level, WHO recommends including general practitioners who
are delivering primary health care outside the (university) hospital as
full members of the teaching staff; adequate academic appointment of
general and particularly rural practitioners is promising to strengthen
training for primary health care in the community [21]. Although
medical training provided by the Institute of General and Family
Medicine involves active practitioners, the still prevailing model of
single-doctor practices and the contractual inflexibility of public
services prevent medical schools from the effective integration of
primary-care practitioners in the faculty staff.
Last but not it is worth mentioning that a growing international
critics of “fragmented, outdated, and static curricula that produce illequipped graduates” [23] and the emerging debate on the future of
medical training have not yet arrived in medical training and faculty
in Germany. Physicians for the 21st century must acquire intimate
knowledge of how complex (health) systems function and have to
incorporate a public health perspective with its emphasis on the health
of populations that goes beyond the individual clinical approach
of medical practitioners [24]. A common denominator of socially
responsible and accountable medical training has to be a deliberate
focus on graduating health professionals who have the skills and desire
to provide health care that meets community needs [25].
In reference to ensure equitable access to health care all over
the federal state of Saxonia-Anhalt, the Faculty of Medicine at the
University of Magdeburg will have to offer courses in health sciences
and epidemiology related to determinants of disparity in health and
rural health care. To overcome the limited exposure to real life situations
in the field, a socially responsive school will require medical students
to engage in community-based activities throughout its curriculum,
assess their competences to care for people living in rural settings and
encourage graduates to settle in underserved areas [26]. The imposition
of greater social accountability into accreditation could be instrumental
in production of a professional workforce that is well aligned with
societal health goals and to develop accountability with regards to core
health performance issues such as equity, quality, and efficiency [23].
Traditional academic excellence focusing on basic scientific
research and sophisticated specialised topics has definitely a lesser
potential to strive for improved healthcare delivery and greater impact
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ISSN: 2167-1079 PHCOA, an open access journal
on people’s health through tied bonds with society [21,26]. Recent
recommendations of the German Council of Science and Humanities
(Wissenschaftsrat), the advisory council on matters of organisation of
the higher education system, on the further development of medical
training in Germany [27] does not adequately address the forthcoming
health-system challenges and even fails to comply with the goal to
find the right balance between biomedical research, teaching and
patient care [28]. Needs orientation of academic training and social
accountability of universities and faculties have not yet achieved the
imperative relevance in the political debate on university and academic
training in Germany.
Conclusions
The growing gap between workforce availability and preparedness
on the one hand, and the demand for safeguarding universal access to
health care in the German state of Saxonia-Anhalt on the other calls for
urgent action. Both the corporatist health sector and medical training
have to be adapted to changing social and societal needs. Innovative
contractual arrangements between statutory health insurance and
providers associations are needed for overcoming the challenges
deriving from the unequal distribution of medical professionals and
the rural exodus of physicians. Medical schools have urgently to adapt
their curricula, research, education and priority setting to current
needs and strive in order to become socially accountable. Public policy
in the health, education and research sector have to create incentives
for this change to happen and ultimately to enforce the structural
changes required for producing adequately prepared health workforce.
Therefore the most brilliant ideas and convincing concepts will certainly
not suffice to change the framework conditions and put the institutional
arrangements right; strong political and smart alliances will be needed
for implementing the required reforms and ensuring universal access
for all citizens in Germany.
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